Rituximab or cyclosporine in the treatment of membranous nephropathy

TY - JOUR

T1 - Rituximab or cyclosporine in the treatment of membranous nephropathy

AU - Fervenza, Fernando C.

AU - Appel, Gerald B.

AU - Barbour, Sean J.

AU - Rovin, Brad H.

AU - Lafayette, Richard A.

AU - Aslam, Nabeel

AU - Jefferson, Jonathan A.

AU - Gipson, Patrick E.

AU - Rizk, Dana V.

AU - Sedor, John R.

AU - Simon, James F.

AU - Mccarthy, Ellen T.

AU - Brenchley, Paul

AU - Sethi, Sanjeev

AU - Avila-casado, Carmen

AU - Beanlands, Heather

AU - Lieske, John C.

AU - Philibert, David

AU - Li, Tingting

AU - Thomas, Lesley F.

AU - Green, Dolly F.

AU - Juncos, Luis A.

AU - Beara-lasic, Lada

AU - Blumenthal, Samuel S.

AU - Sussman, Amy N.

AU - Erickson, Stephen B.

AU - Hladunewich, Michelle

AU - Canetta, Pietro A.

AU - Hebert, Lee A.

AU - Leung, Nelson

AU - Radhakrishnan, Jay

AU - Reich, Heather N.

AU - Parikh, Samir V.

AU - Gipson, Debbie S.

AU - Lee, Dominic K.

AU - Da Costa, Bruno R.

AU - Jüni, Peter

AU - Cattran, Daniel C.

PY - 2019/7/4

Y1 - 2019/7/4

N2 - BACKGROUND B-cell anomalies play a role in the pathogenesis of membranous nephropathy. B-cell depletion with rituximab may therefore be noninferior to treatment with cyclosporine for inducing and maintaining a complete or partial remission of proteinuria in patients with this condition. METHODS We randomly assigned patients who had membranous nephropathy, proteinuria of at least 5 g per 24 hours, and a quantified creatinine clearance of at least 40 ml per minute per 1.73 m2 of body-surface area and had been receiving angiotensinsystem blockade for at least 3 months to receive intravenous rituximab (two infusions, 1000 mg each, administered 14 days apart; repeated at 6 months in case of partial response) or oral cyclosporine (starting at a dose of 3.5 mg per kilogram of body weight per day for 12 months). Patients were followed for 24 months. The primary outcome was a composite of complete or partial remission of proteinuria at 24 months. Laboratory variables and safety were also assessed. RESULTS A total of 130 patients underwent randomization. At 12 months, 39 of 65 patients (60%) in the rituximab group and 34 of 65 (52%) in the cyclosporine group had a complete or partial remission (risk difference, 8 percentage points; 95% confidence interval [CI],-9 to 25; P = 0.004 for noninferiority). At 24 months, 39 patients (60%) in the rituximab group and 13 (20%) in the cyclosporine group had a complete or partial remission (risk difference, 40 percentage points; 95% CI, 25 to 55; P<0.001 for both noninferiority and superiority). Among patients in remission who tested positive for anti-phospholipase A2 receptor (PLA2R) antibodies, the decline in autoantibodies to anti-PLA2R was faster and of greater magnitude and duration in the rituximab group than in the cyclosporine group. Serious adverse events occurred in 11 patients (17%) in the rituximab group and in 20 (31%) in the cyclosporine group (P = 0.06). CONCLUSIONS Rituximab was noninferior to cyclosporine in inducing complete or partial remission of proteinuria at 12 months and was superior in maintaining proteinuria remission up to 24 months. (Funded by Genentech and the Fulk Family Foundation; MENTOR ClinicalTrials.gov number, NCT01180036.)

AB - BACKGROUND B-cell anomalies play a role in the pathogenesis of membranous nephropathy. B-cell depletion with rituximab may therefore be noninferior to treatment with cyclosporine for inducing and maintaining a complete or partial remission of proteinuria in patients with this condition. METHODS We randomly assigned patients who had membranous nephropathy, proteinuria of at least 5 g per 24 hours, and a quantified creatinine clearance of at least 40 ml per minute per 1.73 m2 of body-surface area and had been receiving angiotensinsystem blockade for at least 3 months to receive intravenous rituximab (two infusions, 1000 mg each, administered 14 days apart; repeated at 6 months in case of partial response) or oral cyclosporine (starting at a dose of 3.5 mg per kilogram of body weight per day for 12 months). Patients were followed for 24 months. The primary outcome was a composite of complete or partial remission of proteinuria at 24 months. Laboratory variables and safety were also assessed. RESULTS A total of 130 patients underwent randomization. At 12 months, 39 of 65 patients (60%) in the rituximab group and 34 of 65 (52%) in the cyclosporine group had a complete or partial remission (risk difference, 8 percentage points; 95% confidence interval [CI],-9 to 25; P = 0.004 for noninferiority). At 24 months, 39 patients (60%) in the rituximab group and 13 (20%) in the cyclosporine group had a complete or partial remission (risk difference, 40 percentage points; 95% CI, 25 to 55; P<0.001 for both noninferiority and superiority). Among patients in remission who tested positive for anti-phospholipase A2 receptor (PLA2R) antibodies, the decline in autoantibodies to anti-PLA2R was faster and of greater magnitude and duration in the rituximab group than in the cyclosporine group. Serious adverse events occurred in 11 patients (17%) in the rituximab group and in 20 (31%) in the cyclosporine group (P = 0.06). CONCLUSIONS Rituximab was noninferior to cyclosporine in inducing complete or partial remission of proteinuria at 12 months and was superior in maintaining proteinuria remission up to 24 months. (Funded by Genentech and the Fulk Family Foundation; MENTOR ClinicalTrials.gov number, NCT01180036.)

UR - http://www.scopus.com/inward/record.url?scp=85068552015&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85068552015&partnerID=8YFLogxK

U2 - 10.1056/NEJMoa1814427

DO - 10.1056/NEJMoa1814427

M3 - Article

C2 - 31269364

AN - SCOPUS:85068552015

VL - 381

SP - 36

EP - 46

JO - New England Journal of Medicine

JF - New England Journal of Medicine

SN - 1533-4406

IS - 1

ER -